Chicago P101 - 05/01/23 - Self-scheduling patient form

Self-scheduling Patient Form
Thank you for showing interest in joining our vaccine study! Please note, by answering the following short questionnaire, you will be routed to the next phase of auto scheduling your first appointment.

First Name

Last Name

Primary Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Secondary/Emergency Contact Number

Please enter a valid phone number.Format: (000) 000-0000.

Date of Birth

Date

Today's Date

Date

Age

Gender

Weight and Height

Please list all current prescribed and/or over the counter medications with start dates and dosages.

Please list any current or past medical conditions with diagnosis dates associated.

Have you ever had a previous reaction to a vaccine or medication? Please list which vaccine/medication and describe the reaction.

Have you been hospitalized within the last 12 months? Please list the reason with the date of hospital visit.

For Women of Child Bearing Potential: a. Do you currently use any form of birth control? (Type, Date started) b. Are you currently pregnant or breastfeeding?

Have you received an influenza (flu) vaccine within the last 6 months? If yes, please list the date of receipt.

What type (Brand – Moderna/Pfizer/J&J) of Covid Vaccine and/or Booster shots have you received? Please list dates of receipt.

Have you received any other vaccines in the last 28 days? Please list the type and dates of receipt.

Have you previously participated in a clinical trial? If yes, please describe and list completion date.

Site Address: 7411 Lake St. River Forest, IL 60305 STE L120

Appointment Date and Time

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Select to request a call from our representative:

Please confirm your primary contact number

ComtrakId

Site

Study

Thank you for taking the time to fill out the form. Please click on the Submit button below to schedule your appointment with us